Phase 3: Educational and Ecologic Assessment

At this point, HP-DP staff should be knowledgeable about the social, health, and behavioral and environmental problems that affect the target population. This Phase determines the major causes of the behaviors and environmental conditions identified in the Behavioral and Environmental Assessment. The products of the assessment will become areas for planning an HP-DP program. Green and Kreuter (2005) identified three factors that influence behavior:

  • 1. Predisposing factors, which are strongly associated with a target behavior;
  • 2. Enabling factors, which are strongly associated with the target behavior to allow for individual and group motivation to be realized; and
  • 3. Reinforcing factors, which are strongly associated with a target behavior and that provide the reward for the target behavior to be repeated.

Predisposing, reinforcing, and enabling factors, individually and collectively, predict, in varying degrees, rates of behavior of a target behavior of a population. Application of the PRECEDE/PROCEED Model is based on the premise that the causes of health-related behavior are multifactorial. Therefore, planning and evaluation of changes in rates of behavior(s) need to consider the influence that each causal factor plays in increasing or decreasing the likelihood of a personal action and its potential for an effect on the other factors.

Predisposing factors are primarily psycho-social in nature. They include cognitive and affective aspects such as knowledge, literacy, personal feelings, beliefs, values, personality, and levels of self-confidence or self-efficacy. There are a host of other factors that could predispose behavior, for example, socioeconomic status, age, gender, and ethnicity. These other factors, because they are unchangeable, are not the focus of interventions (e.g., age, gender, ethnicity). All of the demographic factors, however, should be considered in planning an intervention and evaluation.

Predisposing factors commonly addressed by interventions include knowledge, health beliefs, values, attitudes, self-efficacy, behavioral intentions, and existing skills. Some or all of these factors may be relevant to the target population. On the other hand, some may play a more important role in influencing behavior than the others. A careful review of the influences of each of the factors is essential in helping you understand what to target in your intervention.

Enabling factors facilitate the action of an individual or organization. They include the availability, accessibility and affordability of health-related services and community resources. They may include living conditions that act to prohibit action and skills that are needed to enact a behavior. Enabling factors are frequently the focus of community organization, organizational development, and training components of a new HP-DP program. They include the identification of new resources and skills necessary to perform a desirable behavior and organizational actions needed to modify the community environment. Resources include the organization and accessibility of the health facilities, personnel, schools, outreach centers/clinics, or any similar resource. Personal health skills may be taught and may be used to enable specific health actions of a target population. Skills in influencing the community, such as those necessary to promote social action and organizational change, influence the physical and healthcare environment.

Reinforcing factors are either positive or negative feedback that individuals receive from others after taking specific action. This feedback typically influences whether a positive or negative behavior will be repeated or extinquished. Reinforcement may come from a wide variety of individual and combination of sources: a person’s children, family members, social group, peers, coworkers, an employee’s environment and supervisors, and healthcare and social services providers. The physical consequences of behavior need to be acknowledged as reinforcing factors. This may be the relief that asthmatics feel from the correct use of medication, or the positive feelings from physical conditioning and from participation in an exercise program.

There are three criteria to help select which predisposing, enabling, and reinforcing factors should be targeted for modification by an intervention:

  • • Identifying and sorting of factors into three categories;
  • • Setting priorities among categories; and
  • • Establishing priorities within categories.

The first task is to identify and sort the factors into three categories. This listing should be as comprehensive as possible. The data in this list may be obtained through either informal or formal methods. Informal methods may begin with planners using their knowledge, experience, and insight about why a category of behaviors exist. For example, you may suspect that knowledge, health beliefs, and lack of confidence are important predisposing factors related to the target behavior. Such estimates are most often confirmed through interaction with members of the target population. Additional insight may be obtained from use of focus groups, interviews, discussion groups, and questionnaires.

These same methods should be used to gather data from those who are involved in the delivery of intervention components and delivering services in organizations collaborating with the planning group. Based on these informal data, you may want to conduct a more formal assessment. Standard measures of many constructs are available in the literature to adapt for this purpose, including measures of beliefs, self-efficacy, attitudes, behavioral intentions, and social support. Results from a formal survey may be used to confirm findings from the informal approaches.

The second step is to set priorities among the categories. Even if you have a complete inventory of behaviors to target, you cannot analyze and prioritize them at the same time. You must determine sequencing of factors in your intervention. For example, consider a health promotion program that seeks to reduce prostate cancer among inner-city African American men. Consideration should be given to identifying priorities among the three factors for each step of development and sequence. Enabling factors to provide a prostate screening service must be in place before you can begin an educational campaign to address predisposing factors related to the use of the service. Once the enabling and predisposing factors are in place, attention can then be directed to reinforcing factors. The situation demands the following order of development: enabling, predisposing, and reinforcing factors.

The last is step is to establish priorities in the categories. In this step, planners will again use criteria on importance and changeability (see Table 2.1). As in the environmental and behavioral assessment, selection for targeting the three factors is based on an emphasis on highly important and highly changeable variables. When evaluating importance, consideration should be to give the three criteria: prevalence, immediacy, and necessity. Prevalence refers to how widespread the factor is, while immediacy refers to the urgency of the factor. Necessity, on the other hand, gives consideration to factors that are low in prevalence, yet necessary for change.

When assessing changeability, you need to know how much change to expect. A systematic review of the literature may provide HP-DP staff with considerable or limited insight. Application of the meta evaluation and meta analysis methods described in this chapter should be applied to the literature that you identify. The product of this review should enable program staff to estimate the level of change in each of the prioritized factors.

Writing Educational Objectives

At this stage, objectives can be drafted for each target predisposing, enabling, and reinforcing factor of an intervention. Objectives should be drafted, discussed, and finalized, using the four criteria used in writing behavioral and health objectives: who/where, what, how much, and when.

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